Drug-related deaths – the Swedish case Håkan Leifman, director, CAN (Swedish Council for Information on Alcohol and Other Drugs)

Background: reported big increase in DRD: Proportional increase in number of DRDs (all): anchored on 2006 EMCDDA: ST6

Background: According to all reported DRD (Drug Death (DD)) indicators in Sweden: dramatic increases Increase (more than +100% since 2006), especially in opioids: methadone, buprenorphine, fentanyl, oxycodone (thus, opioid pharmaceuticals). Recent years, no decrease in heroin The reported increase: used to in order to support and to criticise the current Swedish drug policy (‘everyone’ is fuelled by an increase!) Is this a true increase, no clear other indications of increased number of PDU? www.can.se 3

Disposition Start to scrutinize the statistical series – changes in methodology (before discussion why an increase in Sweden) Therefore: Analyses of changes in methodology (recording practices) with focus on forensic tox analyses Results of new corrected (adjusted) time series of drug deaths (DD=presences of drugs in deaths) and DRD Why so confusing, lessons to learn, implications www.can.se 4

Approximately 90 000 deaths per year in Sweden Background Flow chart, from a death to a statistic in the GMR (Cause-of-death register) Approximately 90 000 deaths per year in Sweden Forensic investigation About 5 000 per year Requested by the Police Toxicological tests for the presence of many kinds of drugs (national forensic toxicological database at RMV) (basic forensic results in a centralised forensic medicine data base at RMV) Forensic pathologists determine cause of death on death certificate Health care About 85 000 deaths Doctors determine cause of death on death certificate Cause-of-death statistics All 90 000 death certificates sent to National Board of Health and Welfare (NBHW): Coding of all deaths (underlying and contributory), and Updating the General Mortality Register (GMR) From the GMR: Drug-related deaths in Swedish-GMR and EMCDDA-GMR (Selection B) www.can.se 5

Changes in recording practices (methodological changes) Two parts Changes in coding practices for all causes of deaths certificates (done at the National Board of Health and Welfare) based on ICD-10 Changes in practices in toxicological tests (done by the National Board of Forensic Medicine). Almost all DRD passes through forensic investigations The CAN-study focus on the latter by analysing toxicological individual data 2000-2014, with positive and negative finding from 2011, earlier years only the positive cases www.can.se 6

Tramadol: Until 2012 coded as T39.3, after that T40.8. In aNBHW-report focusing mostly on changes in coding practicies 1. Coding practices for all causes of deaths certificates (done at the National Board of Health and Welfare) T50.9: (others, non specified drugs/medicines) not included in the DRD-series, but from 2006/07 more information on the causes of death certificates – deaths previously would be under the T50.9 will now have codes included in the DRD-series Tramadol: Until 2012 coded as T39.3, after that T40.8. T39.3 not included, T40.8 included in the DRD-series NPS: Number increased, previously under T50.9 (not included) from 2014 under T43.6 (included) Dextropropoxifen (DXP): not included and removed from the market in March 2011. Other substances ‘replacing’ DXP included Altogether: all these changes – drive the DRD-time series upward www.can.se 7

2. Changes in the toxicological testing (done at the National Board of Forensic Medicine) (also mentioned in the NBHW-report) Previously – most tests done after request from forensic doctor, but now… More routine screening and More substances routinely screened Lower cut-off (quantification /concentration) (e.g. halving of the methadone quantities) September 2011: new analysis apparatus (mass spectrograph (Time of Flight) Altogether: all these changes – drive the DRD-time series upward – the more you search, the more you find. But more detailed analyses needed, the effect size not assessed www.can.se 8

Example: number of positive fentanyl cases before and after implementation of routine screening (from 0% to 100% screening) www.can.se 9

Analyses of toxdata Methodological effects: lowered threshold value for oxicodone (clear effect) (Source: National forensic toxicological database) www.can.se 10

Analyses of toxdata Methodological effects: lowered threshold value for methadone (weak effect) (Source: National forensic toxicological database) www.can.se 11

However, except for oxycodone… …more or less the same concentration of opioids in blood over time, despite increased screening ’New’ cases detected have not lower quantities of opioids www.can.se 12

Number of forensically examined deaths with positive finding of opioids before and after corrections for increased screening and lowering of threshold values (methadone, oxycodone, DXP) (blue line = corrected time series) Source: national forensic toxicology database. www.can.se 13

Number of drug deaths (opioids, illicit drugs) in forensically examined deaths, with all corrections, anchored on 2008. Source: national forensic toxicology database. www.can.se 14

Still and increase… Substantially lower than what has previously been reported Increase is due to an increase in opioids (methadone, fentanyl, buprenorphine, oxycodone) 70-75% of all drug deaths (and DRD) due to pharmaceutical opioids An increase in most age groups, men and women Strong correlations between drug deaths (presence of drugs) and drug-related deaths NPS not included in my analyses of the tox data; still ’few’ cases: 2015: 21 detected deaths with spice (14 contributed to the deaths), 2010: 1 and 0 cases. Will not change the trend pattern What about alcohol and benzodiazepines? www.can.se 15

Polydrug use Studying alcohol and/or benzodiazepine involvement in opioid deaths - Decrease in relative terms (%) for alcohol - Increase for benzodiazepines (no other combination increase (opioids-alc, opioids-alc-benz) Alcohol cannot explain the increase in opioid deaths Benzodiazepines could be an important contributory factor www.can.se 16

Comparability, conclusions The previous (?) Swedish trend data (without corrections) is not really comparable over time The Swedish level of DRD, but also trends, are not fully comparable with other EU-countries It is not plausible that the Swedish rate of 93/million compared do the EU-average of 19/million mirrors true differences Most likely, also other countries have done methodological changes, along already existing differences Must keep track of changes in statistical time series that are due to methodological changes www.can.se 17

What has happened in Sw during past years? - A new national DRD series, including dextropropoxifen and also including all pharmaceuticals, e.g. benzodiazepines (DXP also in the EMCCDA Selection B series); Includes only poisoning deaths, thus F11 is excluded - National Forensic Board (RMV) and CAN will develop further a time series of DD (presence of different drugs) among forensically investigated deaths; - To be seen as an important complement to the official statistics on DRD and would be rather similar to the EMCDDA recommendations of selection criteria for special registers An action plan on how to reduce DRD from NBHW launched this Spring. www.can.se 18

The report at http://www. can The report at http://www.can.se/Publikationer/rapporter /drug-related-deaths-in-sweden/ www.can.se 19